Prehospital emergency care : official journal of the National Association of EMS Physicians and the National Association of State EMS Directors
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Manual ventilation using a self-inflating bag device paired with a facemask (bag-valve-mask, or BVM ventilation) or invasive airway (bag-valve-device, or BVD ventilation) is a fundamental airway management skill for all Emergency Medical Services (EMS) clinicians. Delivery of manual ventilations is challenging. ⋯ BVM ventilation should be performed using a two-person technique whenever feasible. EMS clinicians should use available techniques and adjuncts to achieve optimal mask seal, improve airway patency, optimize delivery of the correct rate, tidal volume, and pressure during manual ventilation, and allow continual assessment of manual ventilation effectiveness.
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AbstractAirway management competency extends beyond technical skills to encompass a comprehensive approach to optimize patient outcomes. Initial and continuing education for airway management must therefore extend beyond a narrow focus on psychomotor skills and task completion to include appreciation of underlying pathophysiology, clinical judgment, and higher-order decision making. NAEMSP recommends:Active engagement in deliberate practice should be the guiding approach for developing and maintaining competence in airway management. ⋯ Optimization of patient outcomes should be valued over performance of individual airway management skills. Credentialing and continuing education activities in airway management are essential to advance clinicians beyond entry-level competency. Initial and continuing education programs should be responsive to advances in the evidence base and maintain adaptability to re-assess content and expected outcomes on a continual basis.
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Airway management is a critical intervention for patients with airway compromise, respiratory failure, and cardiac arrest. Many EMS agencies use drug-assisted airway management (DAAM) - the administration of sedatives alone or in combination with neuromuscular blockers - to facilitate advanced airway placement in patients with airway compromise or impending respiratory failure who also have altered mental status, agitation, or intact protective airway reflexes. While DAAM provides several benefits including improving laryngoscopy and making insertion of endotracheal tubes and supraglottic airways easier, DAAM also carries important risks. ⋯ EMS clinicians must have the necessary equipment and training to manage patients with failed DAAM, including bag mask ventilation, supraglottic airway devices and surgical airway approaches. Continuous quality improvement for DAAM must include assessment of individual and aggregate performance metrics. Where available for review, continuous physiologic recordings (vital signs, pulse oximetry, and capnography), audio and video recordings, and assessment of patient outcomes should be part of DAAM continuous quality improvement.
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Although pediatric airway and respiratory emergencies represent high-acuity situations, the ability of EMS clinicians to effectively manage these patients is hampered by infrequent clinical exposure and shortcomings in pediatric-specific education. Cognitive gaps in EMS clinicians' understanding of the differences between pediatric and adult airway anatomy and respiratory physiology and pathology, variability in the training provided to EMS clinicians, and decay of the psychomotor skills necessary to safely and effectively manage pediatric patients experiencing respiratory emergencies collectively pose significant threats to the quality and safety of care delivered to pediatric patients. NAEMSP recommends:Pediatric airway education should include discussion of the factors that make pediatric airway management challenging. ⋯ EMS clinicians should receive initial and ongoing education and training in pediatric airway and respiratory conditions that emphasizes the principle of using the least invasive most effective strategies to achieve oxygenation and ventilation. Initial and continuing pediatric-focused education should be structured to maintain EMS clinician competency in the assessment and management of pediatric airway and respiratory emergencies and should be provided on a recurring basis to mitigate the decay of EMS clinicians' knowledge and skills that occurs due to infrequent field-based clinical exposure. Integration of clinician education programs with quality management programs is essential for the development and delivery of initial and continuing education intended to help EMS clinicians attain and maintain proficiency in pediatric airway and respiratory management.
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Devices and techniques such as bag-valve-mask ventilation, endotracheal intubation, supraglottic airway devices, and noninvasive ventilation offer important tools for airway management in critically ill EMS patients. Over the past decade the tools, technology, and strategies used to assess and manage pediatric respiratory and airway emergencies have evolved, and evidence regarding their use continues to grow. NAEMSP recommends:Methods and tools used to properly size pediatric equipment for ages ranging from newborns to adolescents should be available to all EMS clinicians. ⋯ Advanced approaches to pediatric ETI including drug-assisted airway management, apneic oxygenation, and use of direct and video laryngoscopy require further research to more clearly define their risks and benefits prior to widespread implementation. If considering the use of pediatric endotracheal intubation, the EMS medical director must ensure the program provides pediatric-specific initial training and ongoing competency and quality management activities to ensure that EMS clinicians attain and maintain mastery of the intervention. Paramedic use of direct laryngoscopy paired with Magill forceps to facilitate foreign body removal in the pediatric patient should be maintained even when pediatric endotracheal intubation is not approved as a local clinical intervention.